Biological and epidemiological sciences have studied microbes’ development of resistance to antimicrobial agents since the early part of the twentieth century. Yet, global governance responses to antimicrobial resistance (AMR) only began to gain momentum much later. In his authoritative historical account of AMR, Scott Podolsky (2018) identifies the period from 2013 to the present as particularly important in setting the issue on the global agenda for political action. A handful of countries began from the 1970s and onward to make policies to restrict and regulate antibiotic use, as well as to raise healthcare professionals’ and public awareness about appropriate uses of such medications. But while highly successful in curbing AMR, these efforts were mostly made by small to medium-sized states in Northern Europe. The intervening decades have seen growing agreement among public health experts and professionals that mitigating AMR requires coordinated and collective global action. While the need for global coordination to fight AMR might seem obvious, it is, however, very difficult to achieve. Indeed, the latest report from the Interagency Coordination Group on AMR to the UN Secretary General makes clear that AMR is faced with inadequate political commitment and that existing global efforts “are currently too slow and must be accelerated” (IAGC, 2019, p. 6). The complexity of AMR impedes a strong global governance regime and current (as of 2020) global initiatives consist mostly of broad aims and guidelines rather than formal treaties with binding obligations and quantifiable targets. In legal terms, they constitute soft international law rather than hard law instruments, and these softer approaches have been argued to cause little political commitment and progress when it comes to fighting AMR.
The Global Action Plan on AMR
The Global Action Plan (GAP) on AMR illustrates one of the current efforts of establishing global concerted action aimed to reduce the emergence and transmission of AMR. The GAP was recommended in September 2013 by the World Health Organization (WHO) Strategic Technical Advisory Group on AMR, and the recommendation was subsequently adopted in May 2014 as a World Health Assembly resolution. Hence, the WHO started drafting the GAP together with the Food and Agriculture Organization of the United Nations (FAO) and the World Organization for Animal Health (OIE). The GAP was endorsed in May 2015 by the WHO’s 194 member states which were urged to develop and implement national action plans (NAPs) on AMR by 2017 modelled by the GAP’s guidelines. The GAP presents five strategic objectives. These include:
National Action Plans on AMR
As of 31 January 2020, 135 countries report to have developed national action plans (NAPs) to combat AMR, while 50 countries are still in the process of developing one (WHO, 2020). We conducted a systematic content analysis of existing NAPs to explore levels of alignment, both vertically and horizontally (Munkholm and Rubin, forthcoming). Vertical alignment was measured by the extent to which each NAP overlaps with the GAP. Horizontal alignment was explored by measuring the degree to which NAPs overlap within regions and income groups. We found clear income patterns. For instance, low-income countries (LICs) and lower-and-middle-income countries (LMICs) show promising patterns of participation with a very high degree of alignment between their NAPs and the GAP. In comparison, several upper-middle-income countries (UMICs) and high-income countries (HICs) have produced NAPs with much more limited reference to the policy initiatives called for in the GAP. Thus, the poorer the country, the more it seems to share syntax and content with the GAP. One reason for this might be that the GAP has been produced for LICs and LMICs to push forward activities for mitigating AMR challenges in these countries. However, the pace in which the vast majority of NAPs have been produced combined with the breadth of participating member states establish the conditions for what can be called isomorphic mimicry where agenda conformity is preferred over actual action (Andrews, Pritchett and Woolcock, 2017). In fact, very few countries have implemented their NAPs (WHO, FAO, & OIE, 2020), most likely because of different types of capability traps and/or conflicting political concerns. For instance, for many LICs and LMICs, access to antibiotics is a bigger societal problem than AMR (Rochford et al., 2018).
There is a need for new strategies that allow countries to formulate and implement AMR policies that respond to their specific challenges. One way forward is to strengthen political commitment by supplementing the international guidelines of the GAP with binding international agreements. It has been suggested to get inspiration from recent climate agreements such as the Paris Climate Agreement which represents a type of legally binding agreement with “individualized responsibilities” allowing each country to commit to individualized targets and actions determined at the national level but informed by a common global goal (Van Katwyk et al., 2020). It is vital that the AMR policy process does not merely lead to nationally “routinized responses in the form of tick-the-box activities that are designed to produce surface compliance” (Guinn and Straussman, 2019, p. 1725). Next steps for global action to reduce AMR must aim for strengthening the policy process by developing new governance tools rather than focusing more narrowly on pushing forward national implementation of the GAP, which could risk reinforcing a regime of agenda conformity where policies are mainly developed for the consumption of international organizations.
PhD in Global Studies and Sociology of Law – Postdoctoral Researcher at the Department of Social Sciences and Business, Roskilde University, Denmark.
PhD in Political Science – Professor at Department of Social Sciences and Business, Roskilde University, Denmark.